Interdisciplinary Deprescribing of Aspirin Through Prescriber Education and Provision of Patient-Specific Recommendations.

BACKGROUND: Inappropriate aspirin use can lead to increased frequency of bleeding events and poor patient outcomes. OBJECTIVES: Compare current aspirin prescribing to guideline recommendations and analyze the impact of pharmacist education for clinicians with provision of patient-specific recommendations. METHODS: Internal medicine residents received 1 educational session on appropriate aspirin use. Over a 5-month period post-education, 100 patients on aspirin with a clinic appointment were screened and their charts reviewed. Aspirin use was classified based on guideline recommendations as follows: (1) recommended, (2) weigh the risk and benefits, (3) not recommended, (4) dose change recommended, or (5) outside of guideline recommendation. A recommendation for aspirin deprescribing was then communicated to the clinician prior to the patient's appointment. Prescriber practice following the appointment was collected and analyzed. RESULTS: Inappropriate aspirin use occurred in 29% (n = 29) of patients prior to their appointment. Of these, aspirin was not recommended in 65.5% (n = 19), and a dose reduction from 325 mg to 81 mg was recommended in 34.5% (n = 10). Of the 81 patients who kept their appointment, pharmacist recommendations to deprescribe aspirin were communicated to the clincian for 20 patients (24.7%) and resulted in a 55% aspirin deprescription. CONCLUSIONS: The majority of patients identified as using aspirin inappropriately fell into 3 groups: (1) patients taking 325 mg aspirin, (2) patients taking aspirin for primary prevention, and (3) patients taking aspirin concomitantly with an anticoagulant. Strategies that may lead to optimization of aspirin use include lectures and patient-specific chart reviews with pharmacist recommendation.

Comparison of Prescribing Practices with Direct Acting Oral Anticoagulant Protocols.

BACKGROUND: The goal of anticoagulation management programs is to prevent thrombosis while minimizing the risks of hemorrhage. Direct acting oral anticoagulants (DOACs) selectively inhibit coagulation proteins to inhibit thrombosis. Previous studies suggest patient monitoring and education provided through anticoagulation services enhance adherence and decrease adverse outcomes in patients receiving DOAC therapy. OBJECTIVE: The objectives of this study were to describe DOAC prescribing adherence to anticoagulation service protocols and to observe whether enrollment in an anticoagulation service resulted in greater prescribing adherence to DOAC protocols. METHODS: A retrospective cohort study evaluated all initial prescriptions of apixaban, dabigatran, and rivaroxaban at Marshfield Clinic from 19 October 2010 to 21 August 2014. Three algorithms analyzed patient and prescription data extracted from the organization's electronic health record and classified prescriptions as per protocol or not per protocol. The algorithms classified not per protocol prescriptions as off-label indication, renal impairment [estimated glomerular filtration rate (eGFR) <30 ml/min], hepatic impairment (rivaroxaban and apixaban), advanced age >74 years (dabigatran), dose too low, or dose too high. The analysis assessed whether enrollment in the Marshfield Clinic Anticoagulation Service DOAC monitoring process was associated with increased adherence to protocols. RESULTS: In aggregate, 72% of apixaban prescriptions, 52% of dabigatran prescriptions, and 70% of rivaroxaban prescriptions were per protocol. Off-label indications and dosage too low were the most common not per protocol reasons for apixaban and rivaroxaban prescriptions. Age ≥75 years and off-label indication were the most common not per protocol reasons for dabigatran prescriptions. Enrollment in the anticoagulation service process was not associated with increased adherence to protocols. CONCLUSION: A significant proportion of DOAC prescriptions did not adhere to protocol expectations. While enrollment in DOAC management through the Marshfield Clinic Anticoagulation Service was not associated with increased adherence to protocols, opportunities exist to optimize DOAC prescribing. Defining ideal DOAC management requires additional research.

The active patient role and asthma outcomes in an underserved rural community.

PURPOSE: Patient activation, an individual's knowledge, skills, and confidence for managing their own health and health care, can play an important role in the management of chronic conditions. However, few studies have examined patient activation in underserved rural communities. The purpose of this study was to describe patient activation and examine how patient activation is associated with adherence to asthma maintenance medication and disease control in a low-income rural population with asthma. METHODS: We conducted a cross-sectional telephone survey with 98 adults. Patient activation was assessed with the Patient Activation Measure. Adherence to long-term controller (LTC) medications and asthma control were examined using the Morisky Medication Adherence Scale (MMAS) and Asthma Control Test (ACT). Multivariate regression analyses were used to assess the associations between patient activation and: (1) adherence to LTC medications and (2) asthma control. FINDINGS: The majority of participants (50%) were classified in the highest level of patient activation. The least activated participants had lower mean MMAS and ACT scores in comparison to participants who were classified in higher patient activation levels. Multivariate analyses found significant positive associations between patient activation and adherence and asthma control. CONCLUSIONS: Patient activation may be instrumental in low-income rural patients' use of asthma medication and disease control. Study results inform interventions to help patients use asthma medications appropriately and achieve better asthma control. In addition to increasing access to health care services in rural communities, health care professionals also may develop and implement strategies to positively impact rural patients' involvement in care.

Assessment of dabigatran utilization and prescribing patterns for atrial fibrillation in a physician group practice setting.

For years, warfarin and aspirin have been standard therapies for prophylaxis of stroke in atrial fibrillation. In late 2010, dabigatran, an oral direct thrombin inhibitor, became available for use in nonvalvular atrial fibrillation. We sought to evaluate utilization and prescribing patterns of dabigatran in a physician group practice setting. We retrospectively collected prescription data from October 2010 to December 2011 including indication of use, dose, renal function, drug interactions, history of warfarin therapy, and risk assessment scores (CHADS2 and HAS-BLED). Off-label use (history of valve disease or no diagnosis of atrial fibrillation) occurred in 20% (n = 34) of 174 patients. Renal function assessed by Cockcroft-Gault equation identified 1 case of contraindicated use and the need for initial renal dose adjustment in approximately 1/2 of the patients with reduced renal function (15-30 ml/min). Review of anticoagulant use revealed 68% of patients (n = 119) previously received warfarin and ultimately 20% of all patients on dabigatran resumed warfarin therapy. A significant increase in the use of permeability glycoprotein inhibitors and proton pump inhibitors after initiating dabigatran was observed. Nearly 10% of patients had a CHADS2 score of 0. For patients receiving novel oral anticoagulants, prospective inclusion in anticoagulation services and guidance from specific "place in therapy" statements have potential to play a large role in maximizing safety while aiding in continued research.

Designing a pharmacy residency program: focus on a common accreditation challenge.

PURPOSE: One organization's stepwise approach to achieving full compliance in an area often cited for improvement in pharmacy residency accreditation surveys is described. SUMMARY: Principle 4 of the American Society of Health-System Pharmacists (ASHP) accreditation standard for postgraduate year 1 (PGY1) residencies lists requisite components of program design, conduct, and evaluation; many organizations seeking accreditation are evaluated as being in partial compliance with one or more elements of Principle 4. Several years ago, the Marshfield Clinic, a physician group practice in Wisconsin, launched an initiative to expand its postgraduate medical training program to include a PGY1 pharmacy residency. After a gap analysis of current practices and accreditation requirements, monthly meetings of pharmacy, faculty, and corporate leaders were conducted to address program development challenges, with ongoing input from the clinic's division of education. Strategies were developed for meeting all Principle 4 criteria. For example, with regard to component 4.2 (Program Delivery), the clinic developed a residency program handbook including standing operating procedures and a residency preceptor guide with a trainee evaluation scale, professional development resources, and guidance on providing resident feedback. After an internally conducted mock site visit to identify and resolve Principle 4 issues and other compliance issues, the clinic underwent an ASHP site visit and was subsequently accredited by the ASHP Commission on Credentialing. CONCLUSION: Marshfield Clinic used an efficient step-by-step process in the development of its PGY1 pharmacy residency program and achieved full compliance with all of the criteria outlined in Principle 4 of the ASHP accreditation standard.